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Abstract:

Methods of treating, preventing or managing leukemias are disclosed. The
methods encompass the administration of an immunomodulatory compound of
the invention known as Revlimid® or lenalidomide. The invention
further relates to methods of treatment using this compound with
chemotherapy, radiation therapy, hormonal therapy, biological therapy or
immunotherapy. Pharmaceutical compositions and single unit dosage forms
suitable for use in the methods of the invention are also disclosed.

Claims:

1. A method of treating leukemia in a human, which comprises
administering to a human in need thereof a therapeutically effective
amount of 3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dion-
e.

3. The method of claim 1, wherein the leukemia is relapsed, refractory or
resistant to conventional therapy.

4. The method of claim 1, wherein the leukemia is chronic lymphocytic
leukemia.

5. The method of claim 4, wherein the leukemia is refractory or relapsed
chronic lymphocytic leukemia.

6. A method of treating leukemia, which comprises administering to a
patient in need thereof a therapeutically effective amount of
3-(4-amino-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione and a
therapeutically effective amount of a second active agent.

17. The method of claim 1, wherein
3-(4-amino-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione is
administered in the form of a capsule or tablet.

18. The method of claim 1, wherein
3-(4-amino-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione is
administered in an amount of about 25 mg per day for 21 days followed by
seven days rest in a 28 day cycle.

19. The method of claim 18, further comprising administration of
rituximab in an amount of 375 mg/m.sup.2.

Description:

[0001] This application is a continuation-in-part of U.S. patent
application Ser. No. 10/438,213, filed May 15, 2003, which claims the
benefit of U.S. provisional application No. 60/380,842, filed May 17,
2002, and 60/424,600, filed Nov. 6, 2002, the entireties of which are
incorporated herein by reference.

1. FIELD OF THE INVENTION

[0002] This invention relates to methods of treating, preventing or
managing leukemias with an immunomodulatory compound having the chemical
name of 3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione,
which is also known as Revlimid® or Revlimid®. In particular,
this invention encompasses methods of treating, preventing or managing
leukemias, including but not limited to, chronic lymphocytic leukemia,
chronic myelocytic leukemia, acute lymphoblastic leukemia, acute
myelogenous leukemia and acute myeloblastic leukemia, using the compound
alone as a therapeutic.

[0003] The invention also encompasses the use of specific combinations or
"cocktails" of Revlimid® and other therapy, e.g., radiation or other
chemotherapeutics, including but not limited to, anti-cancer agents,
immunosuppressive agents, and anti-inflammatories such as steroids. The
invention also relates to pharmaceutical compositions and dosing regimens
with said compound alone that is as a therapeutic.

2. BACKGROUND OF THE INVENTION

[0004] 2.1 Pathobiology of Cancer

[0005] Cancer is characterized primarily by an increase in the number of
abnormal cells derived from a given normal tissue, invasion of adjacent
tissues by these abnormal cells, or lymphatic or blood-borne spread of
malignant cells to regional lymph nodes and to distant sites
(metastasis). Clinical data and molecular biologic studies indicate that
cancer is a multistep process that begins with minor preneoplastic
changes, which may under certain conditions progress to neoplasia. The
neoplastic lesion may evolve clonally and develop an increasing capacity
for invasion, growth, metastasis, and heterogeneity, especially under
conditions in which the neoplastic cells escape the host's immune
surveillance. Roitt, I., Brostoff, J. and Kale, D., Immunology,
17.1-17.12 (3rd ed., Mosby, St. Louis, Mo., 1993).

[0006] There is an enormous variety of cancers which are described in
detail in the medical literature. Examples includes cancer of the blood,
lung, colon, rectum, prostate, breast, brain, and intestine. The various
forms of the cancers such as leukemias are described in U.S. provisional
application No. 60/380,842, filed May 17, 2002, the entireties of which
are incorporated herein by reference (see, e.g., Section 2.2. Types of
Cancers).

[0007] In particular, leukemia refers to malignant neoplasms of the
blood-forming tissues. Although viruses reportedly cause several forms of
leukemia in animals, causes of leukemia in humans are to a large extend
unknown. The Merck Manual, 944-952 (17th ed. 1999). Transformation
to malignancy typically occurs in a single cell through two or more steps
with subsequent proliferation and clonal expansion. In some leukemias,
specific chromosomal translocations have been identified with consistent
leukemic cell morphology and special clinical features (e.g.,
translocations of 9 and 22 in chronic myelocytic leukemia, and of 15 and
17 in acute promyelocytic leukemia). Acute leukemias are predominantly
undifferentiated cell populations and chronic leukemias more mature cell
forms.

[0008] Acute leukemias are divided into lymphoblastic (ALL) and
non-lymphoblastic (ANLL) types. The Merck Manual, 946-949 (17th ed.
1999). They may be further subdivided by their morphologic and
cytochemical appearance according to the French-American-British (FAB)
classification or according to their type and degree of differentiation.
The use of specific B- and T-cell and myeloid-antigen monoclonal
antibodies are most helpful for classification. ALL is predominantly a
childhood disease which is established by laboratory findings and bone
marrow examination. ANLL, also known as acute myelogenous leukemia or
acute myeloblastic leukemia (AML), occurs at all ages and is the more
common acute leukemia among adults; it is the form usually associated
with irradiation as a causative agent.

[0009] Chronic leukemias are described as being lymphocytic (CLL) or
myelocytic (CML). The Merck Manual, 949-952 (17th ed. 1999). CLL is
characterized by the appearance of mature lymphocytes in blood, bone
marrow, and lymphoid organs. The hallmark of CLL is sustained, absolute
lymphocytosis (>5,000/μL) and an increase of lymphocytes in the
bone marrow. Most CLL patients also have clonal expansion of lymphocytes
with B-cell characteristics. CLL is a disease of middle or old age. In
CML, the characteristic feature is the predominance of granulocytic cells
of all stages of differentiation in blood, bone marrow, liver, spleen,
and other organs. In the symptomatic patient at diagnosis, the total WBC
count is usually about 200,000/μL, but may reach 1,000,000/μL. CML
is relatively easy to diagnose because of the presence of the
Philadelphia chromosome.

[0010] The incidence of cancer continues to climb as the general
population ages, as new cancers develop, and as susceptible populations
(e.g., people infected with AIDS or excessively exposed to sunlight)
grow. In particular, chronic lymphocytic leukemia is an incurable
leukemia with limited therapeutic options for patients with relapsed or
refractory disease. A tremendous demand therefore exists for new methods
and compositions that can be used to treat patients with cancer including
leukemia.

[0011] Many types of cancers are associated with new blood vessel
formation, a process known as angiogenesis. Several of the mechanisms
involved in tumor-induced angiogenesis have been elucidated. The most
direct of these mechanisms is the secretion by the tumor cells of
cytokines with angiogenic properties. Examples of these cytokines include
acidic and basic fibroblastic growth factor (a,b-FGF), angiogenin,
vascular endothelial growth factor (VEGF), and TNF-α.
Alternatively, tumor cells can release angiogenic peptides through the
production of proteases and the subsequent breakdown of the extracellular
matrix where some cytokines are stored (e.g., b-FGF). Angiogenesis can
also be induced indirectly through the recruitment of inflammatory cells
(particularly macrophages) and their subsequent release of angiogenic
cytokines (e.g., TNF-α, bFGF).

[0012] Accordingly, compounds that can control angiogenesis or inhibit the
production of certain cytokines, including TNF-α, may be useful in
the treatment and prevention of various cancers.

[0013] 2.2 Methods of Treating Cancer

[0014] Current cancer therapy may involve surgery, chemotherapy, hormonal
therapy and/or radiation treatment to eradicate neoplastic cells in a
patient (see, for example, Stockdale, 1998, Medicine, vol. 3, Rubenstein
and Federman, eds., Chapter 12, Section IV). Recently, cancer therapy
could also involve biological therapy or immunotherapy. All of these
approaches pose significant drawbacks for the patient. Surgery, for
example, may be contraindicated due to the health of a patient or may be
unacceptable to the patient. Additionally, surgery may not completely
remove neoplastic tissue. Radiation therapy is only effective when the
neoplastic tissue exhibits a higher sensitivity to radiation than normal
tissue. Radiation therapy can also often elicit serious side effects.
Hormonal therapy is rarely given as a single agent. Although hormonal
therapy can be effective, it is often used to prevent or delay recurrence
of cancer after other treatments have removed the majority of cancer
cells. Biological therapies and immunotherapies are limited in number and
may produce side effects such as rashes or swellings, flu-like symptoms,
including fever, chills and fatigue, digestive tract problems or allergic
reactions.

[0015] With respect to chemotherapy, there are a variety of
chemotherapeutic agents available for treatment of cancer. A majority of
cancer chemotherapeutics act by inhibiting DNA synthesis, either
directly, or indirectly by inhibiting the biosynthesis of
deoxyribonucleotide triphosphate precursors, to prevent DNA replication
and concomitant cell division. Gilman et al., Goodman and Gilman's: The
Pharmacological Basis of Therapeutics, Tenth Ed. (McGraw Hill, N.Y.).

[0016] Despite availability of a variety of chemotherapeutic agents,
chemotherapy has many drawbacks. Stockdale, Medicine, vol. 3, Rubenstein
and Federman, eds., ch. 12, sect. 10, 1998. Almost all chemotherapeutic
agents are toxic, and chemotherapy causes significant, and often
dangerous side effects including severe nausea, bone marrow depression,
and immunosuppression. Additionally, even with administration of
combinations of chemotherapeutic agents, many tumor cells are resistant
or develop resistance to the chemotherapeutic agents. In fact, those
cells resistant to the particular chemotherapeutic agents used in the
treatment protocol often prove to be resistant to other drugs, even if
those agents act by different mechanism from those of the drugs used in
the specific treatment. This phenomenon is referred to as pleiotropic
drug or multidrug resistance. Because of the drug resistance, many
cancers prove refractory to standard chemotherapeutic treatment
protocols.

[0017] Still, there is a significant need for safe and effective methods
of treating, preventing and managing cancer, particularly for diseases
that are refractory to standard treatments, such as surgery, radiation
therapy, chemotherapy and hormonal therapy, while reducing or avoiding
the toxicities and/or side effects associated with the conventional
therapies.

[0018] 2.3 IMiDs®

[0019] A number of studies have been conducted with the aim of providing
compounds that can safely and effectively be used to treat diseases
associated with abnormal production of TNF-α. See, e.g., Marriott,
J. B., et al., Expert Opin. Biol. Ther. 1(4):1-8 (2001); G. W. Muller, et
al., Journal of Medicinal Chemistry 39(17): 3238-3240 (1996); and G. W.
Muller, et al., Bioorganic & Medicinal Chemistry Letters 8: 2669-2674
(1998). Some studies have focused on a group of compounds selected for
their capacity to potently inhibit TNF-α production by LPS
stimulated PBMC. L. G. Corral, et al., Ann. Rheum. Dis. 58:(Suppl I)
1107-1113 (1999). These compounds, which are referred to as IMiDs®
(Celgene Corporation) or Immunomodulatory Drugs, show not only potent
inhibition of TNF-α but also inhibition of LPS induced monocyte
IL1β and IL12 production. LPS induced IL6 is also inhibited by
immunomodulatory compounds of the invention, albeit partially. These
compounds are potent stimulators of LPS induced IL10. Id. Particular
examples of IMiDs® include, but are not limited to, the substituted
2-(2,6-dioxopiperidin-3-yl)phthalimides and substituted
2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindoles described in U.S. Pat. Nos.
5,635,517, 6,281,230 and 6,316,471, to G. W. Muller, et al.

3. SUMMARY OF THE INVENTION

[0020] This invention encompasses methods of treating, preventing or
managing certain types of cancer, including primary and metastatic
cancer, as well as cancers that are relapsed, refractory or resistant to
conventional chemotherapy. In particular, methods of this invention
encompass methods of treating, preventing or managing various forms of
leukemias such as chronic lymphocytic leukemia, chronic myelocytic
leukemia, acute lymphoblastic leukemia, acute myelogenous leukemia and
acute myeloblastic leukemia, including leukemias that are relapsed,
refractory or resistant.

[0021] The methods comprise administering to a patient in need of such
treatment, prevention or management a therapeutically or prophylactically
effective amount of an immunomodulatory compound of the invention, or a
pharmaceutically acceptable salt, solvate, hydrate, stereoisomer,
clathrate, or prodrug thereof. In a preferred embodiment, the
immunomodulatory compound is used alone, that is without other
chemotherapeutics.

[0022] In another methods of the invention, an immunomodulatory compound
of the invention is administered in combination with a therapy
conventionally used to treat, prevent or manage cancer. Examples of such
conventional therapies include, but are not limited to, surgery,
chemotherapy, radiation therapy, hormonal therapy, biological therapy,
immunotherapy and combinations thereof.

[0023] This invention also encompasses pharmaceutical compositions, single
unit dosage forms, and dosing regimens which comprise an immunomodulatory
compound of the invention, or a pharmaceutically acceptable salt,
solvate, hydrate, stereoisomer, clathrate, or prodrug thereof, and a
second, or additional, active agent. Second active agents include
specific combinations, or "cocktails," of drugs or therapy, or both.

[0024] The preferred compound to be used in the methods and composition is
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®).

4. BRIEF DESCRIPTION OF FIGURE

[0025] FIG. 1 shows a comparison of the effects of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) and thalidomide in inhibiting the proliferation of
multiple myeloma (MM) cell lines in an in vitro study. The uptake of
[3H]-thymidine by different MM cell lines (MM.1S, Hs Sultan, U266
and RPMI-8226) was measured as an indicator of the cell proliferation.

5. DETAILED DESCRIPTION OF THE INVENTION

[0026] A first embodiment of the invention encompasses methods of
treating, managing, or preventing cancer which comprises administering to
a patient in need of such treatment, management or prevention a
therapeutically or prophylactically effective amount of an
immunomodulatory compound of the invention, or a pharmaceutically
acceptable salt, solvate, hydrate, stereoisomer, clathrate, or prodrug
thereof. In particular, methods of this invention encompass methods of
treating, preventing or managing various forms of leukemias, including
but not limited to, chronic lymphocytic leukemia, chronic myelocytic
leukemia, acute lymphoblastic leukemia, acute myelogenous leukemia and
acute myeloblastic leukemia. In one embodiment, the leukemia is
refractory leukemia, relapsed leukemia or a leukemia that is resistant to
chemotherapy other than an immunomodulatory compound of the invention.

[0027] In a separate and distinct embodiment of the invention, the
immunomodulatory compound of the invention is administered in combination
with another drug ("second active agent") or another therapy for
treating, managing, or preventing cancer. Second active agents include
small molecules and large molecules (e.g., proteins and antibodies),
examples of which are provided herein, as well as stem cells or cord
blood. Methods, or therapies, that can be used in combination with the
administration of an immunomodulatory compound of the invention include,
but are not limited to, surgery, blood transfusions, immunotherapy,
biological therapy, radiation therapy, and other non-drug based therapies
presently used to treat, prevent or manage cancer.

[0028] The invention also encompasses pharmaceutical compositions (e.g.,
single unit dosage forms) that can be used in methods disclosed herein.
Particular pharmaceutical compositions comprise an immunomodulatory
compound of the invention, or a pharmaceutically acceptable salt,
solvate, hydrate, stereoisomer, clathrate, or prodrug thereof, and a
second active agent.

[0029] 5.1 Immunomodulatory Compounds

[0030] Compounds used in the invention include compounds that are racemic,
stereomerically enriched or stereomerically pure. In some embodiments,
pharmaceutically acceptable salts, solvates, hydrates, clathrates, and
prodrugs thereof are included. Preferred compounds used in the invention
are small organic molecules having a molecular weight less than about
1,000 g/mol, and are not proteins, peptides, oligonucleotides,
oligosaccharides or other macromolecules.

[0032] In the most preferred embodiment, "an immunomodulatory compound of
the invention" refers to
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(lenalidomide, also known as Revlimid® or Revlimid®). The
compound 3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
has the following chemical structure:

##STR00001##

[0033] Specific examples of immunomodulatory compounds, include, but are
not limited to, cyano and carboxy derivatives of substituted styrenes
such as those disclosed in U.S. Pat. No. 5,929,117;
1-oxo-2-(2,6-dioxo-3-fluoropiperidin-3yl) isoindolines and
1,3-dioxo-2-(2,6-dioxo-3-fluoropiperidine-3-yl) isoindolines such as
those described in U.S. Pat. No. 5,874,448; the tetra substituted
2-(2,6-dioxopiperdin-3-yl)-1-oxoisoindolines described in U.S. Pat. No.
5,798,368; 1-oxo and 1,3-dioxo-2-(2,6-dioxopiperidin-3-yl) isoindolines,
including, but not limited to, those disclosed in U.S. Pat. No.
5,635,517; substituted 2-(2,6-dioxopiperidin-3-yl) phthalimides and
substituted 2-(2,6-dioxopiperidin-3-yl)-1-oxoisoindoles such as those
described in U.S. Pat. Nos. 6,281,230 and 6,316,471; a class of
non-polypeptide cyclic amides disclosed in U.S. Pat. Nos. 5,698,579 and
5,877,200; thalidomide analogs, including hydrolysis products,
metabolites, and precursors of thalidomide, such as those described in
U.S. Pat. Nos. 5,593,990, 5,629,327, and 6,071,948 to D'Amato; and
isoindole-imide compounds such as those described in U.S. patent
publication no. 2003/0096841, and International Application No.
PCT/US01/50401 (International Publication No. WO 02/059106). The
entireties of each of the patents and patent applications identified
herein are incorporated herein by reference. Immunomodulatory compounds
of the invention do not include thalidomide.

[0034] The immunomodulatory compounds of the invention can either be
commercially purchased or prepared according to the methods described in
the patents or patent publications disclosed herein (see e.g., U.S. Pat.
No. 5,635,517, incorporated herein by reference). Further, optically pure
compounds can be asymmetrically synthesized or resolved using known
resolving agents or chiral columns as well as other standard synthetic
organic chemistry techniques.

[0036] Compounds that are acidic in nature are capable of forming salts
with various pharmaceutically acceptable bases. The bases that can be
used to prepare pharmaceutically acceptable base addition salts of such
acidic compounds are those that form non-toxic base addition salts, i.e.,
salts containing pharmacologically acceptable cations such as, but not
limited to, alkali metal or alkaline earth metal salts and the calcium,
magnesium, sodium or potassium salts in particular. Suitable organic
bases include, but are not limited to, N,N-dibenzylethylenediamine,
chloroprocaine, choline, diethanolamine, ethylenediamine, meglumaine
(N-methylglucamine), lysine, and procaine.

[0037] As used herein and unless otherwise indicated, the term "prodrug"
means a derivative of a compound that can hydrolyze, oxidize, or
otherwise react under biological conditions (in vitro or in vivo) to
provide the compound. Examples of prodrugs include, but are not limited
to, derivatives of immunomodulatory compounds of the invention that
comprise biohydrolyzable moieties such as biohydrolyzable amides,
biohydrolyzable esters, biohydrolyzable carbamates, biohydrolyzable
carbonates, biohydrolyzable ureides, and biohydrolyzable phosphate
analogues. Other examples of prodrugs include derivatives of
immunomodulatory compounds of the invention that comprise --NO,
--NO2, --ONO, or --ONO2 moieties. Prodrugs can typically be
prepared using well-known methods, such as those described in 1 Burger's
Medicinal Chemistry and Drug Discovery, 172-178, 949-982 (Manfred E.
Wolff ed., 5th ed. 1995), and Design of Prodrugs (H. Bundgaard ed.,
Elselvier, N.Y. 1985).

[0038] As used herein and unless otherwise indicated, the terms
"biohydrolyzable amide," "biohydrolyzable ester," "biohydrolyzable
carbamate," "biohydrolyzable carbonate," "biohydrolyzable ureide,"
"biohydrolyzable phosphate" mean an amide, ester, carbamate, carbonate,
ureide, or phosphate, respectively, of a compound that either: 1) does
not interfere with the biological activity of the compound but can confer
upon that compound advantageous properties in vivo, such as uptake,
duration of action, or onset of action; or 2) is biologically inactive
but is converted in vivo to the biologically active compound. Examples of
biohydrolyzable esters include, but are not limited to, lower alkyl
esters, lower acyloxyalkyl esters (such as acetoxylmethyl, acetoxyethyl,
aminocarbonyloxymethyl, pivaloyloxymethyl, and pivaloyloxyethyl esters),
lactonyl esters (such as phthalidyl and thiophthalidyl esters), lower
alkoxyacyloxyalkyl esters (such as methoxycarbonyl-oxymethyl,
ethoxycarbonyloxyethyl and isopropoxycarbonyloxyethyl esters),
alkoxyalkyl esters, choline esters, and acylamino alkyl esters (such as
acetamidomethyl esters). Examples of biohydrolyzable amides include, but
are not limited to, lower alkyl amides, α-amino acid amides,
alkoxyacyl amides, and alkylaminoalkylcarbonyl amides. Examples of
biohydrolyzable carbamates include, but are not limited to, lower
alkylamines, substituted ethylenediamines, amino acids,
hydroxyalkylamines, heterocyclic and heteroaromatic amines, and polyether
amines.

[0039] The immunomodulatory compound of the invention contains a chiral
center, and thus can exist as a racemic mixture of R and S enantiomers.
This invention encompasses the use of stereomerically pure forms of this
compound, as well as the use of mixtures of those forms. For example,
mixtures comprising equal or unequal amounts of the enantiomers may be
used in methods and compositions of the invention. These isomers may be
asymmetrically synthesized or resolved using standard techniques such as
chiral columns or chiral resolving agents. See, e.g., Jacques, J., et
al., Enantiomers, Racemates and Resolutions (Wiley-Interscience, New
York, 1981); Wilen, S. H., et al., Tetrahedron 33:2725 (1977); Eliel, E.
L., Stereochemistry of Carbon Compounds (McGraw-Hill, N.Y., 1962); and
Wilen, S. H., Tables of Resolving Agents and Optical Resolutions p. 268
(E. L. Eliel, Ed., Univ. of Notre Dame Press, Notre Dame, Ind., 1972).

[0040] As used herein and unless otherwise indicated, the term
"stereomerically pure" means a composition that comprises one
stereoisomer of a compound and is substantially free of other
stereoisomers of that compound. For example, a stereomerically pure
composition of a compound having one chiral center will be substantially
free of the opposite enantiomer of the compound. A stereomerically pure
composition of a compound having two chiral centers will be substantially
free of other diastereomers of the compound. A typical stereomerically
pure compound comprises greater than about 80% by weight of one
stereoisomer of the compound and less than about 20% by weight of other
stereoisomers of the compound, more preferably greater than about 90% by
weight of one stereoisomer of the compound and less than about 10% by
weight of the other stereoisomers of the compound, even more preferably
greater than about 95% by weight of one stereoisomer of the compound and
less than about 5% by weight of the other stereoisomers of the compound,
and most preferably greater than about 97% by weight of one stereoisomer
of the compound and less than about 3% by weight of the other
stereoisomers of the compound. As used herein and unless otherwise
indicated, the term "stereomerically enriched" means a composition that
comprises greater than about 60% by weight of one stereoisomer of a
compound, preferably greater than about 70% by weight, more preferably
greater than about 80% by weight of one stereoisomer of a compound. As
used herein and unless otherwise indicated, the term "enantiomerically
pure" means a stereomerically pure composition of a compound having one
chiral center. Similarly, the term "stereomerically enriched" means a
stereomerically enriched composition of a compound having one chiral
center. In other words, the invention encompasses the use of the R or S
enantiomer of immunomodulatory compound in the methods.

[0041] It should be noted that if there is a discrepancy between a
depicted structure and a name given that structure, the depicted
structure is to be accorded more weight. In addition, if the
stereochemistry of a structure or a portion of a structure is not
indicated with, for example, bold or dashed lines, the structure or
portion of the structure is to be interpreted as encompassing all
stereoisomers of it.

[0042] 5.2 Second Active Agents

[0043] An immunomodulatory compound of the invention can be used with or
combined with other pharmacologically active compounds ("second active
agents") in methods and compositions of the invention. It is believed
that certain combinations work synergistically in the treatment of
particular types of cancers, and certain diseases and conditions
associated with, or characterized by, undesired angiogenesis.
Immunomodulatory compounds of the invention can also work to alleviate
adverse effects associated with certain second active agents, and some
second active agents can be used to alleviate adverse effects associated
with immunomodulatory compounds of the invention.

[0044] One or more second active ingredients or agents can be used in the
methods and compositions of the invention together with an
immunomodulatory compound of the invention. Second active agents can be
large molecules (e.g., proteins) or small molecules (e.g., synthetic
inorganic, organometallic, or organic molecules).

[0045] Examples of large molecule active agents include, but are not
limited to, hematopoietic growth factors, cytokines, and monoclonal and
polyclonal antibodies. Typical large molecule active agents are
biological molecules, such as naturally occurring or artificially made
proteins. Proteins that are particularly useful in this invention include
proteins that stimulate the survival and/or proliferation of
hematopoietic precursor cells and immunologically active poietic cells in
vitro or in vivo. Others stimulate the division and differentiation of
committed erythroid progenitors in cells in vitro or in vivo. Particular
proteins include, but are not limited to: interleukins, such as IL-2
(including recombinant IL-II ("rIL2") and canarypox IL-2), IL-10, IL-12,
and IL-18; interferons, such as interferon alfa-2a, interferon alfa-2b,
interferon alfa-n1, interferon alfa-n3, interferon beta-I a, and
interferon gamma-I b; GM-CF and GM-CSF; and EPO.

[0046] Particular proteins that can be used in the methods and
compositions of the invention include, but are not limited to:
filgrastim, which is sold in the United States under the trade name
Neupogen® (Amgen, Thousand Oaks, Calif.); sargramostim, which is sold
in the United States under the trade name Leukine® (Immunex, Seattle,
Wash.); and recombinant EPO, which is sold in the United States under the
trade name Epogen® (Amgen, Thousand Oaks, Calif.).

[0047] Recombinant and mutated forms of GM-CSF can be prepared as
described in U.S. Pat. Nos. 5,391,485; 5,393,870; and 5,229,496; all of
which are incorporated herein by reference. Recombinant and mutated forms
of G-CSF can be prepared as described in U.S. Pat. Nos. 4,810,643;
4,999,291; 5,528,823; and 5,580,755; all of which are incorporated herein
by reference.

[0048] This invention encompasses the use of native, naturally occurring,
and recombinant proteins. The invention further encompasses mutants and
derivatives (e.g., modified forms) of naturally occurring proteins that
exhibit, in vivo, at least some of the pharmacological activity of the
proteins upon which they are based. Examples of mutants include, but are
not limited to, proteins that have one or more amino acid residues that
differ from the corresponding residues in the naturally occurring forms
of the proteins. Also encompassed by the term "mutants" are proteins that
lack carbohydrate moieties normally present in their naturally occurring
forms (e.g., nonglycosylated forms). Examples of derivatives include, but
are not limited to, pegylated derivatives and fusion proteins, such as
proteins formed by fusing IgG1 or IgG3 to the protein or active portion
of the protein of interest. See, e.g., Penichet, M. L. and Morrison, S.
L., J. Immunol. Methods 248:91-101 (2001).

[0049] Antibodies that can be used in combination with compounds of the
invention include monoclonal and polyclonal antibodies. Examples of
antibodies include, but are not limited to, trastuzumab (Herceptin®),
rituximab (Rituxan®), bevacizumab (Avastin®), pertuzumab
(Omnitarg®), tositumomab (Bexxar®), edrecolomab (Panorex®),
and G250. Compounds of the invention can also be combined with, or used
in combination with, anti-TNF-α antibodies.

[0050] Large molecule active agents may be administered in the form of
anti-cancer vaccines. For example, vaccines that secrete, or cause the
secretion of, cytokines such as IL-2, G-CSF, and GM-CSF can be used in
the methods, pharmaceutical compositions, and kits of the invention. See,
e.g., Emens, L. A., et al., Curr. Opinion Mol. Ther. 3(1):77-84 (2001).

[0051] In one embodiment of the invention, the large molecule active agent
reduces, eliminates, or prevents an adverse effect associated with the
administration of an immunomodulatory compound of the invention.
Depending on the particular immunomodulatory compound of the invention
and the disease or disorder begin treated, adverse effects can include,
but are not limited to, drowsiness and somnolence, dizziness and
orthostatic hypotension, neutropenia, infections that result from
neutropenia, increased HIV-viral load, bradycardia, Stevens-Johnson
Syndrome and toxic epidermal necrolysis, and seizures (e.g., grand mal
convulsions). A specific adverse effect is neutropenia.

[0052] Second active agents that are small molecules can also be used to
alleviate adverse effects associated with the administration of an
immunomodulatory compound of the invention. However, like some large
molecules, many are believed to be capable of providing a synergistic
effect when administered with (e.g., before, after or simultaneously) an
immunomodulatory compound of the invention. Examples of small molecule
second active agents include, but are not limited to, anti-cancer agents,
antibiotics, immunosuppressive agents, and steroids.

[0057] Methods of this invention encompass methods of treating, preventing
or managing various types of cancers. In a preferred embodiment, methods
of this invention encompass methods of treating, preventing or managing
various types of leukemias such as chronic lymphocytic leukemia, chronic
myelocytic leukemia, acute lymphoblastic leukemia, acute myelogenous
leukemia, and acute myeloblastic leukemia.

[0058] As used herein, unless otherwise specified, the term "treating"
refers to the administration of a compound of the invention, or other
additional active agent, after the onset of symptoms of the particular
disease or disorder. As used herein, unless otherwise specified, the term
"preventing" refers to the administration prior to the onset of symptoms,
particularly to patients at risk of cancer, and in particular leukemia.
The term "prevention" includes the inhibition of a symptom of the
particular disease or disorder. Patients with familial history of cancer
or leukemia in particular are preferred candidates for preventive
regimens. As used herein and unless otherwise indicated, the term
"managing" encompasses preventing the recurrence of the particular
disease or disorder in a patient who had suffered from it, lengthening
the time a patient who had suffered from the disease or disorder remains
in remission, and/or reducing mortality rates of the patients.

[0060] The term "leukemia" refers malignant neoplasms of the blood-forming
tissues. The leukemia includes, but is not limited to, chronic
lymphocytic leukemia, chronic myelocytic leukemia, acute lymphoblastic
leukemia, acute myelogenous leukemia and acute myeloblastic leukemia. The
leukemia can be relapsed, refractory or resistant to conventional
therapy. The term "relapsed" refers to a situation where patients who
have had a remission of leukemia after therapy have a return of leukemia
cells in the marrow and a decrease in normal blood cells. The term
"refractory or resistant" refers to a circumstance where patients, even
after intensive treatment, have residual leukemia cells in their marrow.

[0062] This invention encompasses methods of treating patients who have
been previously treated for cancer, but are non-responsive to standard
therapies, as well as those who have not previously been treated. The
invention also encompasses methods of treating patients regardless of
patient's age, although some diseases or disorders are more common in
certain age groups. The invention further encompasses methods of treating
patients who have undergone surgery in an attempt to treat the disease or
condition at issue, as well as those who have not. Because patients with
cancer have heterogenous clinical manifestations and varying clinical
outcomes, the treatment given to a patient may vary, depending on his/her
prognosis. The skilled clinician will be able to readily determine
without undue experimentation specific secondary agents, types of
surgery, and types of non-drug based standard therapy that can be
effectively used to treat an individual patient with cancer.

[0063] Methods encompassed by this invention comprise administering one or
more immunomodulatory compound of the invention, or a pharmaceutically
acceptable salt, solvate, hydrate, stereoisomer, clathrate, or prodrug
thereof, to a patient (e.g., a human) suffering, or likely to suffer,
from cancer, particularly leukemia.

[0064] In one embodiment of the invention, an immunomodulatory compound of
the invention can be administered orally and in single or divided daily
doses in an amount of from about 0.10 to about 150 mg/day. In a preferred
embodiment,
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl-piperidine-2,6-dione
(Revlimid®) may be administered in an amount of from about 0.10 to
150 mg per day, from about 1 to about 50 mg per day, or from about 5 to
about 25 mg per day. Specific doses per day include 1, 2, 3, 4, 5, 6, 7,
8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44,
45, 46, 47, 48, 49 or 50 mg per day.

[0065] In a preferred embodiment,
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl-piperidine-2,6-dione
(Revlimid®) may be administered in an amount of from about 1 to 50 mg
per day, or from about 5 to about 25 mg per day to patients with various
types of leukemias such as chronic lymphocytic leukemia, chronic
myelocytic leukemia, acute lymphoblastic leukemia, acute myelogenous
leukemia, and acute myeloblastic leukemia.

[0066] In particular,
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl-piperidine-2,6-dione
(Revlimid®) may be administered to patients with chronic lymphocytic
leukemia in an amount of from about 1 to 50 mg per day, or from about 5
to about 25 mg per day. In a specific embodiment,
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl-piperidine-2,6-dione
(Revlimid®) may be administered to patients with chronic lymphocytic
leukemia in an amount of about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,
14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31,
32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 or
50 mg per day. In a specific embodiment, Revlimid® can be
administered in an amount of about 25 mg/day to patients with chronic
lymphocytic leukemia.

[0067] In one embodiment, the recommended starting dose of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) is 10 mg per day. The dose can be escalated every week to
15, 20, 25, 30, 35, 40, 45 and 50 mg/day. The patients who are dosed
initially at 10 mg and who experience thrombocytopenia or neutropenia
that develops within or after the first four weeks of starting
Revlimid® therapy may have their dosage adjusted according to a
platelet count or absolute neutrophil count (ANC).

[0068] 5.3.1 Combination Therapy with a Second Active Agent

[0069] Specific methods of the invention comprise administering an
immunomodulatory compound of the invention, or a pharmaceutically
acceptable salt, solvate, hydrate, stereoisomer, clathrate, or prodrug
thereof, in combination with one or more second active agents, and/or in
combination with radiation therapy, blood transfusions, or surgery.
Examples of immunomodulatory compounds of the invention are disclosed
herein (see, e.g., section 5.1). Examples of second active agents are
also disclosed herein (see, e.g., section 5.2).

[0070] Administration of an immunomodulatory compound of the invention and
the second active agents to a patient can occur simultaneously or
sequentially by the same or different routes of administration. The
suitability of a particular route of administration employed for a
particular active agent will depend on the active agent itself (e.g.,
whether it can be administered orally without decomposing prior to
entering the blood stream) and the disease being treated. A preferred
route of administration for an immunomodulatory compound of the invention
is orally. Preferred routes of administration for the second active
agents or ingredients of the invention are known to those of ordinary
skill in the art. See, e.g., Physicians' Desk Reference, 1755-1760
(56th ed., 2002).

[0071] In one embodiment of the invention, the second active agent is
administered intravenously or subcutaneously and once or twice daily in
an amount of from about 1 to about 1,000 mg, from about 5 to about 500
mg, from about 10 to about 375 mg, or from about 50 to about 200 mg. The
specific amount of the second active agent will depend on the specific
agent used, the type of disease being treated or managed, the severity
and stage of disease, and the amount(s) of immunomodulatory compounds of
the invention and any optional additional active agents concurrently
administered to the patient. In a particular embodiment, the second
active agent is rituximab, oblimersen (Genasense®), GM-CSF, G-CSF,
EPO, taxotere, irinotecan, dacarbazine, transretinoic acid, topotecan,
pentoxifylline, ciprofloxacin, dexamethasone, vincristine, doxorubicin,
COX-2 inhibitor, IL2, IL8, IL18, IFN, Ara-C, vinorelbine, or a
combination thereof.

[0072] In a specific embodiment, an immunomodulatory compound of the
invention is administered in combination with rituximab to patients with
leukemias. In a specific embodiment, Revlimid® is administered in an
amount of from about 5 to about 25 mg per day to patients with chronic
lymphocytic leukemia in combination with rituximab in an amount of 375
mg/m2.

[0073] In another embodiment, an immunomodulatory compound of the
invention is administered in combination with fludarabine, carboplatin,
and/or topotecan to patients with refractory or relapsed or high-risk
acute myelogenous leukemia.

[0074] In another embodiment, an immunomodulatory compound of the
invention is administered in combination with liposomal daunorubicin,
topotecan and/or cytarabine to patients with unfavorable karotype acute
myeloblastic leukemia.

[0075] In another embodiment, an immunomodulatory compound of the
invention is administered alone or in combination with a second active
ingredient such as vinblastine or fludarabine to patients with various
types of lymphoma, including, but not limited to, Hodgkin's lymphoma,
non-Hodgkin's lymphoma, cutaneous T-Cell lymphoma, cutaneous B-Cell
lymphoma, diffuse large B-Cell lymphoma or relapsed or refractory low
grade follicular lymphoma.

[0076] In another embodiment, GM-CSF, G-CSF or EPO is administered
subcutaneously during about five days in a four or six week cycle in an
amount of from about 1 to about 750 mg/m2/day, preferably in an
amount of from about 25 to about 500 mg/m2/day, more preferably in
an amount of from about 50 to about 250 mg/m2/day, and most
preferably in an amount of from about 50 to about 200 mg/m2/day. In
a certain embodiment, GM-CSF may be administered in an amount of from
about 60 to about 500 mcg/m2 intravenously over 2 hours, or from
about 5 to about 12 mcg/m2/day subcutaneously. In a specific
embodiment, G-CSF may be administered subcutaneously in an amount of
about 1 mcg/kg/day initially and can be adjusted depending on rise of
total granulocyte counts. The maintenance dose of G-CSF may be
administered in an amount of about 300 (in smaller patients) or 480 mcg
subcutaneously. In a certain embodiment, EPO may be administered
subcutaneously in an amount of 10,000 Unit 3 times per week.

[0077] This invention also encompasses a method of increasing the dosage
of an anti-cancer drug or agent that can be safely and effectively
administered to a patient, which comprises administering to a patient
(e.g., a human) an immunomodulatory compound of the invention, or a
pharmaceutically acceptable derivative, salt, solvate, clathrate,
hydrate, or prodrug thereof. Patients that can benefit by this method are
those likely to suffer from an adverse effect associated with anti-cancer
drugs for treating a specific cancer of the blood, skin, subcutaneous
tissue, lymph nodes, brain, lung, liver, bone, intestine, colon, heart,
pancreas, adrenal, kidney, prostate, breast, colorectal, or combinations
thereof. The administration of an immunomodulatory compound of the
invention alleviates or reduces adverse effects which are of such
severity that it would otherwise limit the amount of anti-cancer drug.

[0078] In one embodiment, an immunomodulatory compound of the invention
can be administered orally and daily in an amount of from about 0.10 to
about 150 mg, and preferably from about 1 to about 50 mg, more preferably
from about 5 to about 25 mg prior to, during, or after the occurrence of
the adverse effect associated with the administration of an anti-cancer
drug to a patient. In a particular embodiment, an immunomodulatory
compound of the invention is administered in combination with specific
agents such as heparin, aspirin, coumadin, or G-CSF to avoid adverse
effects that are associated with anti-cancer drugs such as but not
limited to neutropenia or thrombocytopenia.

[0079] In another embodiment, this invention encompasses a method of
treating, preventing and/or managing cancer, which comprises
administering an immunomodulatory compound of the invention, or a
pharmaceutically acceptable salt, solvate, hydrate, stereoisomer,
clathrate, or prodrug thereof, in conjunction with (e.g., before, during,
or after) conventional therapy including, but not limited to, surgery,
immunotherapy, biological therapy, radiation therapy, or other non-drug
based therapy presently used to treat, prevent or manage cancer. The
combined use of the immunomodulatory compounds of the invention and
conventional therapy may provide a unique treatment regimen that is
unexpectedly effective in certain patients. Without being limited by
theory, it is believed that immunomodulatory compounds of the invention
may provide additive or synergistic effects when given concurrently with
conventional therapy.

[0080] As discussed elsewhere herein, the invention encompasses a method
of reducing, treating and/or preventing adverse or undesired effects
associated with conventional therapy including, but not limited to,
surgery, chemotherapy, radiation therapy, hormonal therapy, biological
therapy and immunotherapy. An immunomodulatory compound of the invention
and other active ingredient can be administered to a patient prior to,
during, or after the occurrence of the adverse effect associated with
conventional therapy.

[0081] In one embodiment, an immunomodulatory compound of the invention
can be administered in an amount of from about 0.10 to about 150 mg, and
preferably from about 1 to about 50 mg, more preferably from about 5 to
about 25 mg orally and daily alone, or in combination with a second
active agent disclosed herein (see, e.g., section 5.2), prior to, during,
or after the use of conventional therapy.

[0082] 5.3.2 Use with Transplantation Therapy

[0083] Compounds of the invention can be used to reduce the risk of Graft
Versus Host Disease (GVHD). Therefore, the invention encompasses a method
of treating, preventing and/or managing cancer, which comprises
administering the immunomodulatory compound of the invention, or a
pharmaceutically acceptable salt, solvate, hydrate, stereoisomer,
clathrate, or prodrug thereof, in conjunction with transplantation
therapy.

[0084] As those of ordinary skill in the art are aware, the treatment of
cancer is often based on the stages and mechanism of the disease. For
example, as inevitable leukemic transformation develops in certain stages
of cancer, transplantation of peripheral blood stem cells, hematopoietic
stem cell preparation or bone marrow may be necessary. The combined use
of the immunomodulatory compound of the invention and transplantation
therapy provides a unique and unexpected synergism. In particular, an
immunomodulatory compound of the invention exhibits immunomodulatory
activity that may provide additive or synergistic effects when given
concurrently with transplantation therapy in patients with cancer.

[0085] An immunomodulatory compound of the invention can work in
combination with transplantation therapy reducing complications
associated with the invasive procedure of transplantation and risk of
GVHD. This invention encompasses a method of treating, preventing and/or
managing cancer which comprises administering to a patient (e.g., a
human) an immunomodulatory compound of the invention, or a
pharmaceutically acceptable salt, solvate, hydrate, stereoisomer,
clathrate, or prodrug thereof, before, during, or after the
transplantation of umbilical cord blood, placental blood, peripheral
blood stem cell, hematopoietic stem cell preparation or bone marrow.
Examples of stem cells suitable for use in the methods of the invention
are disclosed in U.S. patent publication nos. 2002/0123141, 2003/0235909
and 2003/0032179, by R. Hariri et al., the entireties of which are
incorporated herein by reference.

[0086] In one embodiment of this method, an immunomodulatory compound of
the invention is administered to patients with leukemias before, during,
or after the transplantation of autologous peripheral blood progenitor
cell.

[0087] In another embodiment, an immunomodulatory compound of the
invention is administered to patients with relapsed leukemia after the
stem cell transplantation.

[0088] 5.3.3 Cycling Therapy

[0089] In certain embodiments, the prophylactic or therapeutic agents of
the invention are cyclically administered to a patient. Cycling therapy
involves the administration of an active agent for a period of time,
followed by a rest for a period of time, and repeating this sequential
administration. Cycling therapy can reduce the development of resistance
to one or more of the therapies, avoid or reduce the side effects of one
of the therapies, and/or improves the efficacy of the treatment.

[0090] Consequently, in one specific embodiment of the invention, an
immunomodulatory compound of the invention is administered daily in a
single or divided doses in a four to six week cycle with a rest period of
about a week or two weeks. The invention further allows the frequency,
number, and length of dosing cycles to be increased. Thus, another
specific embodiment of the invention encompasses the administration of an
immunomodulatory compound of the invention for more cycles than are
typical when it is administered alone. In yet another specific embodiment
of the invention, an immunomodulatory compound of the invention is
administered for a greater number of cycles that would typically cause
dose-limiting toxicity in a patient to whom a second active ingredient is
not also being administered.

[0091] In one embodiment, an immunomodulatory compound of the invention is
administered daily and continuously for three or four weeks at a dose of
from about 0.10 to about 150 mg/d followed by a break of one or two
weeks. In a particular embodiment, an immunomodulatory compound of the
invention is administered in an amount of from about 1 to about 50
mg/day, preferably in an amount of about 25 mg/day for three to four
weeks, followed by one week or two weeks of rest in a four or six week
cycle.

[0092] In a preferred embodiment,
3-(4-amino-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) is administered to patients with leukemia in an amount of
from about 0.10 to about 150 mg per day for 21 days followed by seven
days rest in a 28 day cycle. In the most preferred embodiment,
3-(4-amino-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) is administered to patients with refractory or relapsed
chronic lymphocytic leukemia in an amount of about 25 mg per day for 21
days followed by seven days rest in a 28 day cycle.

[0093] In one embodiment of the invention, an immunomodulatory compound of
the invention and a second active ingredient are administered orally,
with administration of an immunomodulatory compound of the invention
occurring 30 to 60 minutes prior to a second active ingredient, during a
cycle of four to six weeks. In another embodiment of the invention, an
immunomodulatory compound of the invention is administered orally and a
second active ingredient is administered by intravenous infusion.

[0094] In a specific embodiment, one cycle comprises the administration of
from about 10 to about 25 mg/day of Revlimid® and from about 50 to
about 750 mg/m2/day of a second active ingredient daily for three to
four weeks and then one or two weeks of rest. In a preferred embodiment,
rituximab can be administered in an amount of 375 mg/m2 as an
additional active agent to patients with refractory or relapsed chronic
lymphocytic leukemia. Typically, the number of cycles during which the
combinatorial treatment is administered to a patient will be from about
one to about 24 cycles, more typically from about two to about 16 cycles,
and even more typically from about four to about three cycles.

[0095] 5.4 Pharmaceutical Compositions and Dosage Forms

[0096] Pharmaceutical compositions can be used in the preparation of
individual, single unit dosage forms. Pharmaceutical compositions and
dosage forms of the invention comprise an immunomodulatory compound of
the invention, or a pharmaceutically acceptable salt, solvate, hydrate,
stereoisomer, clathrate, or prodrug thereof. Pharmaceutical compositions
and dosage forms of the invention can further comprise one or more
excipients.

[0097] Pharmaceutical compositions and dosage forms of the invention can
also comprise one or more additional active ingredients. Consequently,
pharmaceutical compositions and dosage forms of the invention comprise
the active ingredients disclosed herein (e.g., an immunomodulatory
compound of the invention and a second active agent). Examples of
optional second, or additional, active ingredients are disclosed herein
(see, e.g., section 5.2).

[0099] The composition, shape, and type of dosage forms of the invention
will typically vary depending on their use. For example, a dosage form
used in the acute treatment of a disease may contain larger amounts of
one or more of the active ingredients it comprises than a dosage form
used in the chronic treatment of the same disease. Similarly, a
parenteral dosage form may contain smaller amounts of one or more of the
active ingredients it comprises than an oral dosage form used to treat
the same disease. These and other ways in which specific dosage forms
encompassed by this invention will vary from one another will be readily
apparent to those skilled in the art. See, e.g., Remington's
Pharmaceutical Sciences, 18th ed., Mack Publishing, Easton Pa. (1990).

[0100] Typical pharmaceutical compositions and dosage forms comprise one
or more excipients. Suitable excipients are well known to those skilled
in the art of pharmacy, and non-limiting examples of suitable excipients
are provided herein. Whether a particular excipient is suitable for
incorporation into a pharmaceutical composition or dosage form depends on
a variety of factors well known in the art including, but not limited to,
the way in which the dosage form will be administered to a patient. For
example, oral dosage forms such as tablets may contain excipients not
suited for use in parenteral dosage forms. The suitability of a
particular excipient may also depend on the specific active ingredients
in the dosage form. For example, the decomposition of some active
ingredients may be accelerated by some excipients such as lactose, or
when exposed to water. Active ingredients that comprise primary or
secondary amines are particularly susceptible to such accelerated
decomposition. Consequently, this invention encompasses pharmaceutical
compositions and dosage forms that contain little, if any, lactose other
mono- or di-saccharides. As used herein, the term "lactose-free" means
that the amount of lactose present, if any, is insufficient to
substantially increase the degradation rate of an active ingredient.

[0101] Lactose-free compositions of the invention can comprise excipients
that are well known in the art and are listed, for example, in the U.S.
Pharmacopeia (USP) 25-NF20 (2002). In general, lactose-free compositions
comprise active ingredients, a binder/filler, and a lubricant in
pharmaceutically compatible and pharmaceutically acceptable amounts.
Preferred lactose-free dosage forms comprise active ingredients,
microcrystalline cellulose, pre-gelatinized starch, and magnesium
stearate.

[0102] This invention further encompasses anhydrous pharmaceutical
compositions and dosage forms comprising active ingredients, since water
can facilitate the degradation of some compounds. For example, the
addition of water (e.g., 5%) is widely accepted in the pharmaceutical
arts as a means of simulating long-term storage in order to determine
characteristics such as shelf-life or the stability of formulations over
time. See, e.g., Jens T. Carstensen, Drug Stability: Principles &
Practice, 2d. Ed., Marcel Dekker, NY, N.Y., 1995, pp. 379-80. In effect,
water and heat accelerate the decomposition of some compounds. Thus, the
effect of water on a formulation can be of great significance since
moisture and/or humidity are commonly encountered during manufacture,
handling, packaging, storage, shipment, and use of formulations.

[0103] Anhydrous pharmaceutical compositions and dosage forms of the
invention can be prepared using anhydrous or low moisture containing
ingredients and low moisture or low humidity conditions. Pharmaceutical
compositions and dosage forms that comprise lactose and at least one
active ingredient that comprises a primary or secondary amine are
preferably anhydrous if substantial contact with moisture and/or humidity
during manufacturing, packaging, and/or storage is expected.

[0104] An anhydrous pharmaceutical composition should be prepared and
stored such that its anhydrous nature is maintained. Accordingly,
anhydrous compositions are preferably packaged using materials known to
prevent exposure to water such that they can be included in suitable
formulary kits. Examples of suitable packaging include, but are not
limited to, hermetically sealed foils, plastics, unit dose containers
(e.g., vials), blister packs, and strip packs.

[0105] The invention further encompasses pharmaceutical compositions and
dosage forms that comprise one or more compounds that reduce the rate by
which an active ingredient will decompose. Such compounds, which are
referred to herein as "stabilizers," include, but are not limited to,
antioxidants such as ascorbic acid, pH buffers, or salt buffers.

[0106] Like the amounts and types of excipients, the amounts and specific
types of active ingredients in a dosage form may differ depending on
factors such as, but not limited to, the route by which it is to be
administered to patients. However, typical dosage forms of the invention
comprise an immunomodulatory compound of the invention or a
pharmaceutically acceptable salt, solvate, hydrate, stereoisomer,
clathrate, or prodrug thereof in an amount of from about 0.10 to about
150 mg. Typical dosage forms comprise an immunomodulatory compound of the
invention or a pharmaceutically acceptable salt, solvate, hydrate,
stereoisomer, clathrate, or prodrug thereof in an amount of about 0.1, 1,
2.5, 5, 7.5, 10, 12.5, 15, 17.5, 20, 25, 50, 100, 150 or 200 mg. In a
specific embodiment, a preferred dosage form comprises
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) in an amount of about 1, 2.5, 5, 10, 15, 20, 25 or 50 mg.
Typical dosage forms comprise the second active ingredient in an amount
of 1 to about 1000 mg, from about 5 to about 500 mg, from about 10 to
about 350 mg, or from about 50 to about 200 mg. Of course, the specific
amount of the anti-cancer drug will depend on the specific agent used,
the type of cancer being treated or managed, and the amount(s) of an
immunomodulatory compound of the invention and any optional additional
active agents concurrently administered to the patient.

[0107] 5.4.1 Oral Dosage Forms

[0108] Pharmaceutical compositions of the invention that are suitable for
oral administration can be presented as discrete dosage forms, such as,
but are not limited to, tablets (e.g., chewable tablets), caplets,
capsules, and liquids (e.g., flavored syrups). Such dosage forms contain
predetermined amounts of active ingredients, and may be prepared by
methods of pharmacy well known to those skilled in the art. See
generally, Remington's Pharmaceutical Sciences, 18th ed., Mack
Publishing, Easton Pa. (1990).

[0109] In one embodiment, a preferred dosage form is a capsule or tablet
comprising
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) in an amount of about 1, 2.5, 5, 10, 15, 20, 25 or 50 mg.
In a specific embodiment, a preferred capsule or tablet dosage form
comprises 3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dion-
e (Revlimid®) in an amount of about 5 or 10 mg.

[0110] Typical oral dosage forms of the invention are prepared by
combining the active ingredients in an intimate admixture with at least
one excipient according to conventional pharmaceutical compounding
techniques. Excipients can take a wide variety of forms depending on the
form of preparation desired for administration. For example, excipients
suitable for use in oral liquid or aerosol dosage forms include, but are
not limited to, water, glycols, oils, alcohols, flavoring agents,
preservatives, and coloring agents. Examples of excipients suitable for
use in solid oral dosage forms (e.g., powders, tablets, capsules, and
caplets) include, but are not limited to, starches, sugars,
micro-crystalline cellulose, diluents, granulating agents, lubricants,
binders, and disintegrating agents.

[0111] Because of their ease of administration, tablets and capsules
represent the most advantageous oral dosage unit forms, in which case
solid excipients are employed. If desired, tablets can be coated by
standard aqueous or nonaqueous techniques. Such dosage forms can be
prepared by any of the methods of pharmacy. In general, pharmaceutical
compositions and dosage forms are prepared by uniformly and intimately
admixing the active ingredients with liquid carriers, finely divided
solid carriers, or both, and then shaping the product into the desired
presentation if necessary.

[0112] For example, a tablet can be prepared by compression or molding.
Compressed tablets can be prepared by compressing in a suitable machine
the active ingredients in a free-flowing form such as powder or granules,
optionally mixed with an excipient. Molded tablets can be made by molding
in a suitable machine a mixture of the powdered compound moistened with
an inert liquid diluent.

[0114] Suitable forms of microcrystalline cellulose include, but are not
limited to, the materials sold as AVICEL-PH-101, AVICEL-PH-103 AVICEL
RC-581, AVICEL-PH-105 (available from FMC Corporation, American Viscose
Division, Avicel Sales, Marcus Hook, Pa.), and mixtures thereof. An
specific binder is a mixture of microcrystalline cellulose and sodium
carboxymethyl cellulose sold as AVICEL RC-581. Suitable anhydrous or low
moisture excipients or additives include AVICEL-PH-103® and Starch
1500 LM.

[0115] Examples of fillers suitable for use in the pharmaceutical
compositions and dosage forms disclosed herein include, but are not
limited to, talc, calcium carbonate (e.g., granules or powder),
microcrystalline cellulose, powdered cellulose, dextrates, kaolin,
mannitol, silicic acid, sorbitol, starch, pre-gelatinized starch, and
mixtures thereof. The binder or filler in pharmaceutical compositions of
the invention is typically present in from about 50 to about 99 weight
percent of the pharmaceutical composition or dosage form.

[0116] Disintegrants are used in the compositions of the invention to
provide tablets that disintegrate when exposed to an aqueous environment.
Tablets that contain too much disintegrant may disintegrate in storage,
while those that contain too little may not disintegrate at a desired
rate or under the desired conditions. Thus, a sufficient amount of
disintegrant that is neither too much nor too little to detrimentally
alter the release of the active ingredients should be used to form solid
oral dosage forms of the invention. The amount of disintegrant used
varies based upon the type of formulation, and is readily discernible to
those of ordinary skill in the art. Typical pharmaceutical compositions
comprise from about 0.5 to about 15 weight percent of disintegrant,
preferably from about 1 to about 5 weight percent of disintegrant.

[0117] Disintegrants that can be used in pharmaceutical compositions and
dosage forms of the invention include, but are not limited to, agar-agar,
alginic acid, calcium carbonate, microcrystalline cellulose,
croscarmellose sodium, crospovidone, polacrilin potassium, sodium starch
glycolate, potato or tapioca starch, other starches, pre-gelatinized
starch, other starches, clays, other algins, other celluloses, gums, and
mixtures thereof.

[0121] Active ingredients of the invention can be administered by
controlled release means or by delivery devices that are well known to
those of ordinary skill in the art. Examples include, but are not limited
to, those described in U.S. Pat. Nos. 3,845,770; 3,916,899; 3,536,809;
3,598,123; and 4,008,719, 5,674,533, 5,059,595, 5,591,767, 5,120,548,
5,073,543, 5,639,476, 5,354,556, and 5,733,566, each of which is
incorporated herein by reference. Such dosage forms can be used to
provide slow or controlled-release of one or more active ingredients
using, for example, hydropropylmethyl cellulose, other polymer matrices,
gels, permeable membranes, osmotic systems, multilayer coatings,
microparticles, liposomes, microspheres, or a combination thereof to
provide the desired release profile in varying proportions. Suitable
controlled-release formulations known to those of ordinary skill in the
art, including those described herein, can be readily selected for use
with the active ingredients of the invention. The invention thus
encompasses single unit dosage forms suitable for oral administration
such as, but not limited to, tablets, capsules, gelcaps, and caplets that
are adapted for controlled-release.

[0122] All controlled-release pharmaceutical products have a common goal
of improving drug therapy over that achieved by their non-controlled
counterparts. Ideally, the use of an optimally designed
controlled-release preparation in medical treatment is characterized by a
minimum of drug substance being employed to cure or control the condition
in a minimum amount of time. Advantages of controlled-release
formulations include extended activity of the drug, reduced dosage
frequency, and increased patient compliance. In addition,
controlled-release formulations can be used to affect the time of onset
of action or other characteristics, such as blood levels of the drug, and
can thus affect the occurrence of side (e.g., adverse) effects.

[0123] Most controlled-release formulations are designed to initially
release an amount of drug (active ingredient) that promptly produces the
desired therapeutic effect, and gradually and continually release of
other amounts of drug to maintain this level of therapeutic or
prophylactic effect over an extended period of time. In order to maintain
this constant level of drug in the body, the drug must be released from
the dosage form at a rate that will replace the amount of drug being
metabolized and excreted from the body. Controlled-release of an active
ingredient can be stimulated by various conditions including, but not
limited to, pH, temperature, enzymes, water, or other physiological
conditions or compounds.

[0124] 5.4.3 Parenteral Dosage Forms

[0125] Parenteral dosage forms can be administered to patients by various
routes including, but not limited to, subcutaneous, intravenous
(including bolus injection), intramuscular, and intraarterial. Because
their administration typically bypasses patients' natural defenses
against contaminants, parenteral dosage forms are preferably sterile or
capable of being sterilized prior to administration to a patient.
Examples of parenteral dosage forms include, but are not limited to,
solutions ready for injection, dry products ready to be dissolved or
suspended in a pharmaceutically acceptable vehicle for injection,
suspensions ready for injection, and emulsions.

[0126] Suitable vehicles that can be used to provide parenteral dosage
forms of the invention are well known to those skilled in the art.
Examples include, but are not limited to: Water for Injection USP;
aqueous vehicles such as, but not limited to, Sodium Chloride Injection,
Ringer's Injection, Dextrose Injection, Dextrose and Sodium Chloride
Injection, and Lactated Ringer's Injection; water-miscible vehicles such
as, but not limited to, ethyl alcohol, polyethylene glycol, and
polypropylene glycol; and non-aqueous vehicles such as, but not limited
to, corn oil, cottonseed oil, peanut oil, sesame oil, ethyl oleate,
isopropyl myristate, and benzyl benzoate.

[0127] Compounds that increase the solubility of one or more of the active
ingredients disclosed herein can also be incorporated into the parenteral
dosage forms of the invention. For example, cyclodextrin and its
derivatives can be used to increase the solubility of an immunomodulatory
compound of the invention and its derivatives. See, e.g., U.S. Pat. No.
5,134,127, which is incorporated herein by reference.

[0128] 5.4.4 Topical and Mucosal Dosage Forms

[0129] Topical and mucosal dosage forms of the invention include, but are
not limited to, sprays, aerosols, solutions, emulsions, suspensions, eye
drops or other ophthalmic preparations, or other forms known to one of
skill in the art. See, e.g., Remington's Pharmaceutical Sciences,
16th and 18th eds., Mack Publishing, Easton Pa. (1980 & 1990);
and Introduction to Pharmaceutical Dosage Forms, 4th ed., Lea & Febiger,
Philadelphia (1985). Dosage forms suitable for treating mucosal tissues
within the oral cavity can be formulated as mouthwashes or as oral gels.

[0130] Suitable excipients (e.g., carriers and diluents) and other
materials that can be used to provide topical and mucosal dosage forms
encompassed by this invention are well known to those skilled in the
pharmaceutical arts, and depend on the particular tissue to which a given
pharmaceutical composition or dosage form will be applied. With that fact
in mind, typical excipients include, but are not limited to, water,
acetone, ethanol, ethylene glycol, propylene glycol, butane-1,3-diol,
isopropyl myristate, isopropyl palmitate, mineral oil, and mixtures
thereof to form solutions, emulsions or gels, which are non-toxic and
pharmaceutically acceptable. Moisturizers or humectants can also be added
to pharmaceutical compositions and dosage forms if desired. Examples of
such additional ingredients are well known in the art. See, e.g.,
Remington's Pharmaceutical Sciences, 16th and 18th eds., Mack
Publishing, Easton Pa. (1980 & 1990).

[0131] The pH of a pharmaceutical composition or dosage form may also be
adjusted to improve delivery of one or more active ingredients.
Similarly, the polarity of a solvent carrier, its ionic strength, or
tonicity can be adjusted to improve delivery. Compounds such as stearates
can also be added to pharmaceutical compositions or dosage forms to
advantageously alter the hydrophilicity or lipophilicity of one or more
active ingredients so as to improve delivery. In this regard, stearates
can serve as a lipid vehicle for the formulation, as an emulsifying agent
or surfactant, and as a delivery-enhancing or penetration-enhancing
agent. Different salts, hydrates or solvates of the active ingredients
can be used to further adjust the properties of the resulting
composition.

6. EXAMPLES

[0132] Certain embodiments of the invention are illustrated by the
following non-limiting example.

[0133] 6.1 Toxicology Studies

[0134] The effects of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) on cardiovascular and respiratory function are
investigated in anesthetized dogs. Two groups of Beagle dogs
(2/sex/group) are used. One group receives three doses of vehicle only
and the other receives three ascending doses of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione (2, 10,
and 20 mg/kg). In all cases, doses of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione or
vehicle are successively administered via infusion through the jugular
vein separated by intervals of at least 30 minutes.

[0135] The cardiovascular and respiratory changes induced by
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione are
minimal at all doses when compared to the vehicle control group. The only
statistically significant difference between the vehicle and treatment
groups is a small increase in arterial blood pressure (from 94 mmHg to
101 mmHg) following administration of the low dose of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione. This
effect lasts approximately 15 minutes and is not seen at higher doses.
Deviations in femoral blood flow, respiratory parameters, and Qtc
interval are common to both the control and treated groups and are not
considered treatment-related.

[0136] 6.2 Clinical Studies in Patients

[0137] 6.2.1 Treatment of Chronic Lymphocytic Leukemia

[0138] 3-(4-Amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidin-2,6-dione
(Revlimid®) was orally administered to patients with refractory or
relapsed chronic lymphocytic leukemia (CLL) in an amount of 25 mg per day
for 21 days followed by seven days rest on a 28 day cycle. Twenty seven
patients of median age of 64 years (range: 47-75) were enrolled.
Seventeen patients had Stage III or IV disease. Absolute lymphocyte
counts were measured at Day 0, 7 and 30. Response was assessed at day 30
and monthly thereafter using the NCI-WG 1996 criteria. Patients with
stable disease or better response were continued on therapy for a maximum
of 12 months while those with progressive disease received rituximab (375
mg/m2) added to Revlimid®. Patients were considered evaluable
for response if they completed at least two months of treatment.

[0139] All patients were available for toxicity and 13 out of 18 patients
available for response evaluation. Nine patients on treatment were early
for response assessment. Five patients achieved complete response and
four patients achieved partial response. Three patients achieved stable
disease (continued on treatment). Overall response rate in the 13
evaluable patients was 69%, while objective response rate defined as
(complete response, partial response and stable disease) was 92.3%. Only
one patient had progressive disease after three months of treatment.

[0141] The study result shows that Revlimid® is effective in treating
leukemia, particularly chronic lymphocytic leukemia.

[0142] 6.2.2 Treatment of Relapsed Multiple Myeloma

[0143] 4-(Amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione
(Actimid®) was administered to patients with relapsed/refractory
multiple myeloma. The study was conducted in compliance with Good
Clinical Practices. Patients were at least 18 years old, had been
diagnosed with multiple myeloma (with paraprotein in serum and/or urine),
and were considered refractory to treatment after at least two cycles of
treatment, or have relapsed after two cycles of treatment.

[0144] Patients who have progressive disease, according to the Southwest
Oncology Group (SWOG) criteria, on their prior regimen are considered
treatment refractory. Relapse following remission is defined as >25%
increase in M component from baseline levels; reappearance of the M
paraprotein that had previously disappeared; or a definite increase in
the size and number of lytic bone lesions recognized on radiographs.
Patients may have had prior therapy with thalidomide, provided they were
able to tolerate the treatment. A Zubrod performance status of 0 to 2 is
required for all patients.

[0145] 4-(Amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione is
administered to patients at doses of 1, 2, 5, or 10 mg/day for up to four
weeks; at each dose level, three patients are initially enrolled. Dosing
occurs at approximately the same time each morning; all doses are
administered in the fasted state (no eating for at least two hours prior
to dosing and two hours after dosing).
4-(Amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione doses are
administered in an ascending fashion such that patients in the first
cohort receive the lowest dose of
4-(amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione (1 mg/day) and
escalation to the next higher dose level occurs only following the
establishment of safety and tolerability at the current dose. If one out
of three patients at any dose level experience dose limiting toxicity
(DLT), three additional patients are enrolled at that dose. If none of
the three additional patients experience DLT, escalation to the next dose
level occurs; dose escalations continue in a similar fashion until the
MTD is established or the maximum daily dose (10 mg/day) is attained.
However, if one of the three additional patients enrolled experiences
DLT, the MTD has been reached. If two or more of the three additional
patients enrolled experience DLT, the MTD is judged to have been exceeded
and three additional patients are enrolled at the preceding dose level to
confirm the MTD. Once the MTD has been identified, four additional
patients are enrolled at that dose level so that a total of 10 patients
is treated at the MTD.

[0146] Blood sampling for analysis of pharmacokinetic parameters is
performed on Days 1 and 28 according to the following sampling schedule:
pre-dose, 0.25, 0.5, 0.75, 1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, 12, 18, and 24
hours post-dose. An additional blood sample is collected at each weekly
visit for the determination of
4-(amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione levels. Total
urine collections are also made with urine pooled according to the
following time intervals post-dose: 0 to 4, 4 to 8, 8 to 12, and 12 to 24
hours. Safety assessments are made by monitoring adverse events, vital
signs, ECGs, clinical laboratory evaluations (blood chemistry,
hematology, lymphocyte phenotyping, and urinalysis), and physical
examination at specific times during the study.

[0147] Results of interim pharmacokinetic analyses obtained following
single- and multiple-dose administration of
4-(amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione to multiple
myeloma patients are presented below in Tables 1 and 2. These data show
that 4-(amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione was
steadily absorbed at all dose levels in relapsed multiple myeloma
patients. Maximum plasma concentrations occurred at a median Tmax of
between 2.5 and 2.8 hours post-dose at Day 1 and between 3 and 4 hours
post-dose at Week 4. At all doses, plasma concentrations declined in a
monophasic manner after reaching Cmax. The start of the elimination
phase occurred between 3 and 10 hours post-dose at Day 1 and Week 4,
respectively.

[0148] These data also showed that after 4 weeks of dosing,
4-(amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione accumulated to
a small extent (mean accumulation ratios ˜1.02 to 1.52 and
˜0.94 to 1.62 for Cmax and AUC.sub.(0-τ), respectively).
There was almost a dose proportional increase in AUC.sub.(0-τ) and
Cmax values with increasing dose. A five-fold higher dose of
4-(amino)-2-(2,6-dioxo(3-piperidyl))-isoindoline-1,3-dione produced a
3.2- and 2.2-fold increase in Cmax at Day 1 and Week 4,
respectively. Similarly, a 5-fold increase in dose resulted in a 3.6- and
2.3-fold increase in AUC.sub.(0-τ), at Day 1 and Week 4,
respectively.

[0150] Two Phase 1 clinical studies of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
(Revlimid®) have been conducted to identify the maximum tolerated
dose (MTD) in patients with refractory or relapsed multiple myeloma.
These studies have also characterized the safety profile of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione when
ascending doses of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione were
given orally for up to 4 weeks. Patients started
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
treatment at 5 mg/day with subsequent escalation to 10, 25, and 50
mg/day. Patients were enrolled for 28 days at their assigned dose, with
the option of extended treatment for those who did not exhibit disease
progression or experience dose limiting toxicity (DLT). Patients were
evaluated for adverse events at each visit and the severity of these
events was graded according to the National Cancer Institute (NCI) Common
Toxicity Criteria. Patients were discontinued if they experienced DLT
(Grade 3 or greater non-hematological, or Grade 4 hematological
toxicity).

[0151] In this study, 27 patients were enrolled. All patients had relapsed
multiple myeloma and 18 (72%) were refractory to salvage therapy. Among
these patients, 15 had undergone prior autologous stem cell
transplantation and 16 patients had received prior thalidomide treatment.
The median number of prior regimens was 3 (range 2 to 6).

[0152] Blood and urine samples were collected for analysis of
pharmacokinetic parameters on Days 1 and 28. Blood samples were collected
according to the following sampling schedule: pre-dose, 0.25, 0.5, 0.75,
1, 1.5, 2, 2.5, 3, 4, 6, 8, 10, 12, 18, and 24 hours post-dose. In
addition, a blood sample was collected at each weekly clinic visit for
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
determination. Total urine was collected and pooled according to the
following time intervals post-dose: 0 to 4, 4 to 8, 8 to 12, and 12 to 24
hours. Response to treatment was assessed by M-protein quantification (by
immunoelectrophoresis) from serum and a 24-hour urine collection, with
creatinine clearance and 24-hour protein calculations undertaken at
screening, baseline, Weeks 2 and 4, and monthly thereafter (or upon early
termination). Bone marrow aspirations and/or tissue biopsy are also
performed at Months 3, 6 and 12 if a patient's paraprotein serum
concentration or 24-hour urine protein excretion declined to the next
lower level, based on best response criteria. Preliminary results for the
28-day treatment period are summarized below.

[0153] Preliminary pharmacokinetic analyses based on these two studies
indicated that AUC and Cmax values increase proportionally with dose
following single and multiple doses in multiple myeloma patients (as was
seen in healthy volunteers). Further, there was no evidence of
accumulation with multiple dosing as single dose AUC.sub.(0-∞) was
comparable to multiple dose AUC0-τ following the same dose of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione. Similar
to healthy volunteer studies, double peaks were observed. Exposure in
multiple myeloma patients appeared to be slightly higher based on
Cmax and AUC values as compared to healthy male volunteers while
clearance in multiple myeloma patients was lower than it was in healthy
volunteers, consistent with their poorer renal function (both as a
consequence of their age and their disease). Finally,
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione
half-live in patients was shorter than in healthy volunteers (mean 8
hours, ranging up to 17 hours).

[0154] In this study, the first cohort of 3 patients was treated for 28
days at 5 mg/day without any dose limiting toxicity (DLT). The second
cohort of 3 patients subsequently commenced therapy at 10 mg/day.
Patients in the second 10 mg/day of
3-(4-amino-1-oxo-1,3-dihydro-isoindol-2-yl)-piperidine-2,6-dione cohort
tolerated treatment well.

[0155] 6.2.4 Treatment of Relapsed or Refractory Multiple Myeloma

[0156] Patients with relapsed and refractory Dune-Salmon stage III
multiple myeloma, who have either failed at least three previous regimens
or presented with poor performance status, neutropenia or
thrombocytopenia, are treated with up to four cycles of combination of
melphalan (50 mg intravenously), an immunomodulatory compound of the
invention (about 1 to 150 mg orally daily), and dexamethasone (40 mg/day
orally on days 1 to 4) every four to six weeks. Maintenance treatment
consisting of daily an immunomodulatory compound of the invention and
monthly dexamethasone are continued until the disease progression. The
therapy using an immunomodulatory compound of the invention in
combination with melphalan and dexamethasone is highly active and
generally tolerated in heavily pretreated multiple myeloma patients whose
prognosis is otherwise poor.

[0157] The embodiments of the invention described above are intended to be
merely exemplary, and those skilled in the art will recognize, or will be
able to ascertain using no more than routine experimentation, numerous
equivalents of specific compounds, materials, and procedures. All such
equivalents are considered to be within the scope of the invention and
are encompassed by the appended claims.